Septic abortion, an infected abortion complicated by fever, endometritis, and paramefritis, remains one of the most serious threats to women's health worldwide. Although morbidity and mortality from septic abortion are infrequent in countries in which induced abortion is legal, suffering and death from this process are widespread in many developing countries in which abortion is either illegal or inaccessible. Septic abortion is a paradigm of preventive medicine.

The World Health Organization (WHO) estimates that 21.6 million unsafe abortions occur each year and that 47,000 deaths from unsafe abortion occur in the world every year.

Diagnostic criteria, investigations, treatment and referral criteria: -

AT LEVEL 1 (SOLO PHYSICIAN CLINIC) & LEVEL 2(6-10 BEDDED PHC)

After suspecting a case of septic abortion, the following investigations are done and treatment started simultaneously.

Investigations include the following: -

•           Routine investigations are mandatory to know the status of patients

•           Haemoglobin, blood group& Rh status, BT,CT.

•           Urine complete and microscopic examination.

•           Temperature monitoring

•           Renal function tests(blood urea, serum creatinine)

•           Blood sugar levels.

•           HIV, HBsAg, HCV status.

•           Total leucocyte count & differential leucocyte count(TLC&DLC)

•           Ultrasonography abdomen & pelvic organs.

•           X-ray chest & X-ray abdomen.

Treatment:-

•           Confirm diagnosis of pregnancy with urine pregnancy test.

•           Perform physical examination.

•           Perform pelvic examination with attention to uterine size and position, other pelvic pathology.

•           Obtain ultrasound examination.

•           IN line access to be maintained. Provide prophylactic antibiotics:

REGIMEN A:-

i.             Injection aqueous penicillin 5 million units i/v 6 hourly after sensitivity test or injection ampicillin 500 mg to 1gm i/v 6 hourly(to cover gram positive bacteria)

ii.             Injection gentamicin 60-80 mg i/v 8 hourly after ruling out renal failure(to cover gram negative bacilli)

iii.              Injection metronidazole 500mg i/v 8 hourly(to cover anaerobes)

REGIMEN B:-

I.                  Injection ciprofloxacin 500mg i/v 12 hourly

II.               Injection metronidazole 500mg i/v 8 hourly

REGIMEN C: FOR MORE SEVERE INFECTIONS

I.                Injection cefotaxime 1 gm i/v 12 hourly or injection ceftriaxone 1 g i/v 12 hourly.

II.                 Injection metronidazole 500mg i/v 8 hourly.

III.                 Injection gentamicin 60-80 mg i/v or i/rn 12 hourly.

·       Psychological support.

·       Refer to higher center in severe cases for further management.

LEVEL 3: 100 BEDDED COMMUNITY HEALTH CENTRE:

In addition to investigations already mentioned, following investigations to be added:

·       Liver function teste.

·       Platelet count & PTI

·       Serum electrolytes

·       Urine & vaginal cultures.

·       Blood culture

·       Input output charting

Treatment :-

In addition to the treatment outlined above for level 1 & level 2, following measures can be instituted:

·       Prophylactic anti gas gangrene serum (8000 units) and anti tetanus serum (3000 units) intramuscularly are given if there is history of interference.

·       Oxygenation by face mask in severe cases.

·       Uterine curettage: if patient’s condition is stable, within 1 hour of antibiotic therapy, evacuation of the uterus by gentle curettage to remove infected products. If general condition is low at admission, curettage after 6-8 hours of antibiotic therapy and treatment of hypovolemia is done.

Treatment of complications: -

·       A rapid initial assessment is needed to determine the severity of the problem. If the patient has been symptomatic for several days, more generalized, serious illness may be present.

·       with more advanced gestations, there is greater risk of perforation and of retained tissue. Perforation markedly increases the risk of serious sepsis. the abdominal and pelvic examinations merit special attention.

·       Ideal management is immediate re-evacuation in the ambulatory clinic or the emergency room.

·       outpatient management of pelvic inflammatory disease is appropriate for patients with early postabortal infection limited to the uterine cavity in addition to uterine evacuation. One such regimen is ceftriaxone 250 mg by intramuscular injection (or other third generation cephalosporin such as cefoxitin, ceftizoxime, or cefotaxime) plus doxycycline 100 mg orally twice a day for 14 days, with or without metronidazole 500 mg orally twice a day for l4 days.

Level 4: 100 or more bedded district hospital:-

Along with management mentioned above, we have to avoid serious consequences of infection, including hysterectomy and death.

•           One time-honored regimen for severe pelvic sepsis is penicillin (5 million units intravenously [iv] every 6 hours) or ampicillin (2 g iv every 6 hours) combined with gentamicin (2 mg/kg loading dose, followed by 1.5 mg/kg every 8 hours or 5 mg/kg every 24 hours depending on blood levels and renal status).

•           Laparotomy will be needed if the patient does not respond to uterine evacuation and adequate medical therapy. Other indications are uterine perforation with suspected bowel injury, pelvic abscess, and clostridial myometritis. Although ultrasound-guided percutaneous needle aspiration of pelvic abscesses is practiced, in critically ill women with severe postabortal sepsis, hysterectomy will likely be needed in addition to drainage of any abscess.

•           Patients with severe sepsis and septic shock should be managed in intensive care settings in collaboration with physicians and nurses trained in critical care medicine. Principles of management are aggressive source control with antibiotics and early hemodynamic resuscitation.

•           Vasopressors are added if the patient remains hypotensive despite adequate volume resuscitation or in patients who develop cardiogenic pulmonary edema. Norepinephrine should be the first line agent used for the management of refractory hypotension in the setting of septic shock followed by dopamine.

•           Anemia is corrected with packed red blood cells to hemoglobin of 8 g/dl. Fresh frozen plasma, platelets or cryoprecipitate should be used only when there is clinical or laboratory evidence of coagulopathy.

Conclusion:-

Death and serious complications from abortion-related infection are almost entirely avoidable.